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Concurrent Disorders – Overcoming a Dual Diagnosis with the Help of Hope Rehab Thailand

Concurrent Disorders – Overcoming a Dual Diagnosis with the Help of Hope Rehab Thailand

by Hope Rehab Team

Topic at a glance:

The term concurrent disorders –formerly called dual diagnosis, or in layman’s terms ‘double trouble’- refers to the combination of mental health and substance misuse issues. Examples of concurrent disorders include PTSD or clinical depression and alcohol addiction, ADHD and cocaine addiction, or Generalized Anxiety Disorder and Benzodiazepine dependency.

Hope Rehab Pool Chilling Out

How frequently do mental health issues coexist with substance misuse?

While there are variations as to the degree that substance abuse and mental health disorders coexist depending on the mental health diagnosis or type of substance abuse someone is struggling with, the general rule is that it is more likely than not that both are present at the same time.

What is the link between Mental Health and Substance Use problems?

The link between mental health and substance use problems is manifold:

It is therefore important to understand that Mental health and substance problems interact with one another in multiple and complex ways, and these interactions changes both the course and the outcome of the problems individuals experience. In short, it’s complicated!

Why is it Important to Know about Concurrent Disorders?

Compared to an individual suffering from either an addiction OR a mental illness alone, individuals suffering from concurrent disorders are more likely to:

How are Concurrent Disorders assessed?

Given the complexity and multiple ways in which mental health and substance use problems interact, an assessment of such problems requires skill and time and it is rarely complete or accurate if completed in one short session. Not surprisingly, individuals are often misdiagnosed and therefore at risk for receiving inadequate, unnecessary or insufficient treatment for their problems.

A comprehensive assessment by a skilled clinician trained in the areas of mental health and substance use is therefore highly recommended. At Hope Rehab Center, we provide skilled care through our multidisciplinary team, and we often work in collaboration with clients’ physicians in order to guarantee best possible treatment outcomes for our residents.

Depression

Depression is one of the most common mental health concerns of modern times. While depression rates are high for substance users and non-users alike, the lifetime prevalence of depression for substance users is approximately 24% higher than in the general population. Worldwide, depression has risen to unprecedented proportions and the World Health Organization now predicts epidemic levels of depression by the year 2020. In clinical terms, depression is sometimes referred to as Depressive Disorders or Mood Disorders.

Hope Pool

What is Depression?

Many people use the term depression to describe sad mood or feeling ‘blue’. This, however, is far from the experience of clinical depression which can take on different forms, including:

These symptoms are so severe that they greatly impact individuals’ ability to work or study, and/or be able to maintain meaningful relationships. If the symptoms last more than two weeks, it is considered a major depressive episode.

Persistent Depressive Disorder (Dysthymia)

This is considered a milder form of depression, with some of the same symptoms as described above, but lasting for at least 2 years. Individuals experiencing dysthymia have a tendency to look at the glass half empty, and typically cannot recall a time in their lives when they have ever been truly happy or even content. In the past, this type of depression was referred to as Depressive Personality Disorder.

Bipolar Illness (formerly called manic depressive illness)

Individuals experience extremes in mood, alternating between periods of extreme depression and mania. The hallmark of the latter are excessive energy and a decreased need for sleep, typically accompanied by a sense of grandiosity and high risk behaviours such as drug use, promiscuity or gambling.

Unlike major depressive illness which may be recurrent but is very much treatable, bipolar illness is chronic in nature and requires skilled intervention that includes medication. Not surprisingly, Bipolar illness is the most frequently misdiagnosed mental illness in the context of substance use, given that the ups and downs in moods caused by substance use can easily be mistaken as depression and mania to the untrained eye. Bipolar illness can take on various forms such as bipolar I or II, rapid cycling bipolar, all of which causing individuals difficulties in functioning to at least some degree.

How is depression linked to substance use?

In the context of substance use and recovery from addiction, depression can show up in various ways, including but not limited to:

How is Depression Treated?

Drug induced symptoms of depression often clear with prolonged abstinence and may not need any specialized treatment. Additionally, many therapeutic interventions helpful for the treatment of addiction are equally helpful in the treatment of depression, such as cognitive behavioural therapy (CBT). If symptoms persist, treatment is readily available and the choice of treatment strongly depends on type, severity and chronicity of symptoms, as well as individual preferences. For example, mild to moderate depression can be treated with short-term cognitive behavioural therapy (CBT) and changes in lifestyle. This type of treatment includes a focus on challenging and changing negative thoughts, setting small behavioural goals to achieve healthy routines as they pertain to physical exercise, diet and sleep.

Severe depression and Persistent Depressive Disorders on the other hand typically require a combination antidepressant medication and psychotherapy for best and lasting results. Bipolar disorder I is one of the most debilitating mental health disorders and typically requires long-term and multi-faceted interventions that include medication, community support and specialized forms of therapy, such as Interpersonal and Social Rhythm Therapy.

How is Depression Treated?

Drug induced symptoms of depression often clear with prolonged abstinence and may not need any specialized treatment. Additionally, many therapeutic interventions helpful for the treatment of addiction are equally helpful in the treatment of depression, such as cognitive behavioural therapy (CBT). If symptoms persist, treatment is readily available and the choice of treatment strongly depends on type, severity and chronicity of symptoms, as well as individual preferences. For example, mild to moderate depression can be treated with short-term cognitive behavioural therapy (CBT) and changes in lifestyle. This type of treatment includes a focus on challenging and changing negative thoughts, setting small behavioural goals to achieve healthy routines as they pertain to physical exercise, diet and sleep.

Severe depression and Persistent Depressive Disorders on the other hand typically require a combination antidepressant medication and psychotherapy for best and lasting results. Bipolar disorder I is one of the most debilitating mental health disorders and typically requires long-term and multi-faceted interventions that include medication, community support and specialized forms of therapy, such as Interpersonal and Social Rhythm Therapy.

What Hope Offers for those Suffering from Depression

Hope Rehab Thailand draws on multiple therapeutic interventions helpful in addressing not only the symptoms of depression, but also contributory and causal factors. These interventions include:

Cognitive Behavioural Therapy (CBT):

Hope Rehab Center offers weekly CBT group therapy sessions to help residents to identify, challenge and change negative thoughts that typically contribute to, and maintain a depressed mood.

Individual Counselling Sessions:

Every resident has two weekly individual counselling sessions to address issues specific to the individual, such as blocks to creating a healthy anti-depression lifestyle, negative Core Beliefs or interpersonal issues.

Mindfulness & Mediation:

At Hope Rehab, we offer daily guided meditation practice, as well as weekly individual and group mindfulness sessions. These practices can be helpful to individuals suffering from depression as they learn to disengage from negative thoughts, tolerate difficult emotions and intentionally direct their focus on positives rather than negatives.

Daily Gratitude Circle:

Learning to focus on what we have, on what is working, on what we do well is a helpful tool in countering depression’s focus on personal failures and shortcomings, and on the proverbial ‘the glass half empty philosophy’.

Yoga:

Research shows that a regular yoga practice supports individuals’ journey towards improved physical, emotional and mental health and spiritual healing. At Hope Rehab Center, we offer various styles of yoga to ensure everyone can participate in, and harvest yoga’s vast benefits. Types of yoga offered include flow yoga, hot stone meditation and yoga or restorative yoga.

Healthy Lifestyle:

At Hope Rehab, we emphasize a healthy lifestyle, which includes daily physical exercise, healthy nutritious meals, solid routines around bedtime, mandatory therapy sessions, and a strong community focus to enhance social and emotional health.

Afternoon Activities & Weekly Excursions:

Following our mandatory morning program, residents are encouraged to participate in daily afternoon activities and organized weekend outings. Getting actively involved in social and other life enhancing activities is particularly important for those suffering from depression, as social isolation and a loss of interest in mood enhancing activities are very common symptoms of depression.

Recovery Meetings:

Hope Rehab Center offers addictions focused recovery meetings three times weekly, each with a slightly different focus. This allows attendees to connect with others through sharing of individual struggles and stories of survival pertaining to addictions and mental health recovery. For individuals suffering from depression who typically isolate, learning they are not alone with their difficulties is a wonderful invitation to belong and participate in community again.

Anxiety

Next to depression, anxiety is the most frequently diagnosed mental health concerns of our time, and substance users are 20-40% more likely to experience anxiety disorders as compared to the general population. Conversely, individuals diagnosed with any Anxiety Disorders are at higher risk of developing addictive behaviors, and Generalized Anxiety Disorder was most frequently associated with alcohol and drug problems. Anxiety is also often experienced by those suffering from depression.

Group Meditation Hope Rehab Thailand

What is Anxiety?

Everyone experiences anxiety sometimes; anxiety is closely related to the stress response in our body, which alarms us to any potential danger and is thus crucial for our survival. This automatic fight, flight or freeze response to danger can be noticed as tightness in the chest, an accelerated heartbeat, gastrointestinal problems, racing thoughts about impeding catastrophies or constant worrying, and difficulties thinking clearly.

If Everyone Experiences Anxiety, Why is it a Problem?

Our stress response can be seen like a smoke alarm: it is very helpful when real danger exists, such as a fire. It is not so helpful when this alarm system goes off indiscriminately, constantly and for no good reason. For individuals suffering from General Anxiety Disorder (GAD), this is the case: they constantly worry about potential and disastrous ‘what ifs’ of the future, they experience chronic bodily symptoms such as angina or Irritable Bowel Syndrome (IBS), and they feel tense and unable to relax or sleep. Among the various forms of anxiety disorders, GAD is the one most often experienced by substance users.

How Do I Know that My Levels of Anxiety are Beyond What is Considered ‘Normal’?

We all experience anxiety sometimes; no doubt about that. It is very normal, for example, to experience anxiety when going for a job interview or entering rehab for the first time; in short, when we face uncertainty and when circumstances and events are outside of our control. While most of us manage these short-lived anxiety provoking situations without lasting problems, individuals suffering from anxiety disorders may feel so stressed and become so worried about all the potential ‘what ifs’ of the situation that they feel unable to cope, and they are thus inclined to avoid and withdraw. This typically starts in one area of one’s life, for example when we are socially anxious we may avoid invitations to social events.

Over time, anxiety silently slithers into other areas of our life, making us believe we don’t have what it takes to meet the challenge at hand. Eventually, if we let it, anxiety tends to shrink our life to the point where we are afraid to face any challenge at all, no matter how minor. In short, if anxiety interferes with day to day functioning as it pertains to social relationships, works or leisure, or if it renders us unable live life fully, then it is time to seek help.

Are There Different Types of Anxiety, and What is the Overlap with Substance Abuse?

Anxiety Disorders often precede substance use and they are the most common mental health concern experienced among individuals suffering from alcoholism. For example, individuals diagnosed with an anxiety disorders are 50% more likely to engage in problematic alcohol use compared to the general population. Apart from the aforementioned Generalized Anxiety Disorder (GAD), anxiety symptoms can be a reflection of the following specific anxiety disorders:

Post-Traumatic Stress Disorder (PTSD):

Trauma is unfortunately rather common in substance users, either in form of childhood trauma preceding addictive behaviors, or trauma (such as sexual assault) experienced as a consequence of substance abuse. Individuals suffering from PTSD are 20-40% more likely to develop problematic substance use or other addictive behaviors compared to those not affected by PTSD, and conversely, PTSD prevalence among substance users is at least 50% higher compared to the general population.

Obsessive-Compulsive Disorder (OCD):

This can involve highly intrusive and unwanted thoughts, coupled with some compulsive behavior such as repeated checking or handwashing. While many of us double-check things and tasks to ensure we have done them to our satisfaction, individuals suffering from OCD are never satisfied that they’ve done things right, and they may therefore be unable to complete any task for fear of not doing it well enough. Based on current research, OCD is least associated with substance misuse, potentially due to low levels of impulsive behaviors so commonly observed in substance users.

Social Anxiety Disorder (SAD)

involves fear of social contacts and relationships, and individuals with SAD are two to three times more likely to abuse alcohol compared to the general population. SAD is often, but not always, a consequence of interpersonal trauma such as bullying or violence. Individuals suffering from social anxiety report fear of being embarrassed, judged or ridiculed by others, and they often avoid social events like the plague. Individuals with SAD are two to three times more likely to abuse alcohol compared to the general population.

Entering any form of treatment, especially treatment involving group therapy, is especially frightening to SAD sufferers and needs to be addressed if treatment is to be successful. At Hope rehab, we assist individuals affected by SAD by initially limiting and only gradually increasing group therapy time, by allowing participation at their own pace, and by providing initial extra support, for example by assigning a buddy.

How are Anxiety Disorders treated?

As anxiety symptoms can be mimicked, exacerbated or caused by substance use or withdrawal from substance use, abstinence alone may suffice to alleviate or eliminate symptoms of anxiety. For those symptoms persisting or even increasing past the initial withdrawal phase, treatment options range from medication, cognitive-behavioral therapy and mindfulness approaches. Comprehensive anxiety treatment will address physical, mental, emotional and behavioral aspects of anxiety, including:

A Word about Medication

Many individuals suffering from anxiety or depression enter rehab with prescribed medications, such as antidepressants for depression or anti-anxiety medication. All too often, residents are eager to stop taking such medication in an attempt to be completely ‘drug free’. It is, however, very important to distinguish between medications prescribed by a medical professional for the treatment of a diagnosed mental health problem on one hand, and illegal substances often taken excessively on the other hand. While the former often brings about mood stabilization and increase levels of day to day functioning , illegal substances tend to have the opposite effect: they destabilize, make for unpredictable moods and behaviours, and interfere with individuals’ functioning in all areas of life.

While a desire to rely on non-pharmacological tools such as mindfulness and thought challenging to manage one’s moods is very much desirable, making changes to established medication regimes typically results in at least temporary instability and should therefore be carefully timed, planned and monitored. At Hope Rehab, we work in careful collaboration with residents’ prescribing physicians prior to considering making any changes to established medication regimes. Naturally, there are exceptions to this rule considering the potential for misuse or abuse of some prescription medications, most notably benzodiazepines, opiate medication and ADHD medications. While these types of medications may alleviate suffering if taken as prescribed and for the general population, they are potentially dangerous in the hands of an addict. For these reasons, we at Hope Rehab suggest a planned gradual cessation of these types of medications, ideally prior to entry into treatment, or as part of early recovery.

What Hope offers for those suffering from Anxiety:

As for depression, Hope Rehab Center offers multiple interventions that can help address difficulties anxiety, including:

Cognitive Behavioural Therapy (CBT):

Hope Rehab Center offers weekly CBT group therapy sessions during which residents learn to identify, challenge and change anxious types of thinking, such as catastrophizing, overestimation of the likelihood feared disasters will happen, and the underestimation of one’s own ability to cope.

Individual Counselling Sessions:

Every resident has two weekly individual counselling sessions to address issues specific to the individual, such as avoidance behaviors, which typically work to maintain and increase problems with anxiety.

Mindfulness & Mediation:

At Hope Rehab, we offer daily guided meditation practice, as well as weekly individual and group mindfulness sessions. Mindfulness can teach those suffering from anxiety grounding practices, and how to live with uncertainty. It invites us to stay non-judgmental and curious about our emotions, rather than judging or avoiding them with some sort of quick ‘fix it’. Most importantly, mindfulness teaches us how to intentionally bring our attention to this present moment, rather than chronically worrying about imagined ‘what ifs’ of the future. Regular meditation practice can work to calm an anxious mind, and ultimately make for lessened reactivity.

Yoga:

At Hope Rehab Center, we offer various styles of yoga to ensure everyone can participate in, and harvest yoga’s vast benefits. Types of yoga offered include flow yoga, hot stone meditation and yoga or restorative yoga. Pranayama or breathing practices taught in yoga are particularly helpful to counter an unquiet and anxious mind, and a restless body.

Healthy Lifestyle:

At Hope Rehab, we emphasize a healthy lifestyle, which includes daily physical exercise, healthy nutritious meals, solid routines around bedtime and mandatory therapy sessions, and a strong community focus to enhance social and emotional health.

Afternoon Activities & Weekly Excursions:

Following our mandatory morning program, residents have the opportunity to engage in sports, such as Muay Thai boxing, or art and social activities. Through participation in initially challenging activities, individuals with anxiety counter avoidance behaviors and gradually regain self-confidence. Participation in weekly art activities may help anxious individuals to express and self soothe difficult emotions through art.

Recovery Meetings:

Hope Rehab Center offers addictions focused recovery meetings three times weekly, each with a slightly different focus. This allows attendees to connect with others through sharing of individual struggles and stories of survival pertaining to addictions and mental health recovery. For individuals struggling with social anxiety in particular, learning to share one’s story in front of group and being nevertheless accepted into a community, can be powerful exposure therapy and thus counter typical avoidance behaviors.

Personality Disorders

Personality disorders are very common in those seeking help with addictive behaviors. Antisocial Personality Disorder, Borderline Personality Disorder and Narcissistic Personality Disorder are the most frequently associated with substance abuse. For example, there are estimates that approximately 80 % of individuals with an Antisocial Personality Disorder and 60-70 % of individuals with Borderline Personality Disorder will end up abusing illegal substances, and/or display other forms of addictive behaviors.

What are Personality Disorders?

Personality Disorders can be defined as enduring patterns of thinking and behaving that deviate significantly from standard cultural norms, and these patterns typically cause significant impairment in all areas of functioning. Individuals with personality disorders usually display strongly inflexible and rigid ways of thinking, perceiving and responding to the world around them. They also tend to be unable to adapt to changing contexts or circumstances, and they are very much resistant to change.

Are there Different Types of Personality Disorders?

In short, yes. The Diagnostic Statistical Manual (DSM-V) lists currently ten different types of personality disorder, and as mentioned above, three of those are most commonly associated with serious substance abuse problems:

Antisocial Personality Disorder:

Individuals with this diagnosis display a profound and consistent disregard for societal rules or social norms, based on the belief that rules somehow don’t apply to them. Individuals with this personality disorder tend to be overrepresented in the criminal justice system, as they typically do not hesitate to violate the rights and property of others.

Borderline Personality Disorder (BPD):

More commonly diagnosed in women, this disorder is characterized by pronounced difficulties regulating one’s emotions, a poor self-image and a tendency to instigate drama and crisis in interpersonal relationships and occupational settings alike. Individuals suffering from BPD may resort to self-harm, and they have a tendency to resort to suicidal ideation or suicidal gestures as a way of coping with distress.

Narcissistic Personality Disorder:

Individuals with this disorder display a strong sense of grandiosity, a need for admiration. They tend to feel superior towards others and are likely to dominate interpersonal interactions.

Why are Personality Disorders so Difficult to Treat in Rehab Settings?

Individuals with comorbid personality and substance use disorders pose significant conundrums to addictions rehab centers as they:

Not surprisingly, this complexity translates into a need for more specialized and longer-term treatment, and treatment requires highly skilled staff. Individuals with comorbid substance abuse and personality disorders may manage to stay abstinent during short-term treatment, but they are unlikely to change their maladaptive and engrained way of being in the world in this time frame. This, together with the fact that such individuals tend to not engage in after care programming unfortunately makes for a higher risk of relapse following short-term treatment completion.

What treatment does Hope Rehab Center offer for personality disordered clients?

It is important to remember that personality difficulties exist on a continuum, ranging from adaptive/useful ways of being in the world on one end of the continuum, to maladaptive/unhelpful ways of being in the world on the other end of the continuum. Most of us, substance dependent or not, display at least some behaviors on the maladaptive and unhelpful end of the spectrum when we are in distress, and when things are not going well for us.

While we do not offer specialized long-term treatment for specific personality disorders at Hope Rehab Center, we carefully assess in which life areas and to what degree individuals struggle. Based on this assessment, our skilled team members tailor individual therapy sessions to address these specific needs and challenges and to improve overall functioning. Furthermore, Hope Rehab Center offers proven interventions to address addictive behaviors, anxiety and depression, all of which typically accompany personality problems and when treated improve day to day functioning.

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